General Surgery Education Across Three Continents

Surgical education has seen tremendous changes in the US over the past decade. The Halstedian training model of see one, do one, teach one that governed surgical training for almost 100 years has been replaced by the achievement of the ACGME competencies, milestones, entrustable professional activities (EPAs), and acquisition of surgical skill outside the operating room on simulators. Several of these changes in American medical education have been influenced by educators and training paradigms abroad. In this paper, we review the training paradigms for surgeons in the UK, Japan, and Mexico to allow comparisons with the US training paradigm and promote the exchange of ideas

Surgical assessment system reflexes and facilitates the developing the surgical skills of trainees for the Laparoscopic Distal Gastrectomy

Background: To assess laparoscopic distal gastrectomy (LDG) for gastric cancer (GC), the Japanese Operative Rating Scale (JORS) for LDG has been developed. This study evaluated the learning curve of the initial experience of LDG for GC using JORS-LDG.Methods: Thirty-one cases of LDG were performed by a trainee. The trainee and an instructor scored the surgical performance using JORS-LDG immediately after LDG. The 31 cases were evenly divided into early phase (EP), middle phase (MP), and late phase (LP).Results: The trainee successfully completed all cases of LDG without any complications. There were also no severe postoperative complications with Clavien–Dindo classification grade III or higher. The average JORS-LDG points were stable after 24 cases of experience in the CUSUM analysis. The median JORS-LDG points in EP were significantly lower than those in LP (EP: MP: LP = 43.5: 44.3: 45.5, P = 0.02). In operative data, procedure time, bleeding, and the drain fluid amylase level were correlated with the JORS-LDG points.Conclusion: The JORS-LDG scoring system is a practical tool to evaluate surgical performance in the initial LDG experience

Delphi Method Consensus-Based Identification of Primary Trauma Care Skills Required for General Surgeons in Japan

Purpose General surgeons at regional hospitals should have the primary trauma care skills necessary to treat critically ill trauma patients to withstand transfer. This study was conducted to identify a consensus on primary trauma care skills for general surgeons. Methods An initial list of acute care surgical skills was compiled, and revised by six trauma experts (acute care surgeons); 33 skills were nominated for inclusion in the Delphi consensus survey. Participants (councilors of the Japanese Society for Acute Care Surgery) were presented with the list of 33 trauma care skills and were asked (using web-based software) to rate how strongly they agreed or disagreed (using a 5-point Likert scale) with the necessity of each skill for a general surgeon. The reliability of consensus was predefined as Cronbach’s α ≥ 0.8, and trauma care skills were considered as primarily required when rated 4 (agree) or 5 (strongly agree) by ≥ 80% participants. Results There were 117 trauma care specialists contacted to participate in the Delphi consensus survey panel. In the 1st round, 85 specialists participated (response rate: 72.6%). In the 2nd round, 66 specialists participated (response rate: 77.6%). Consensus was achieved after two rounds, reliability using Cronbach’s α was 0.94, and 34 items were identified as primary trauma care skills needed by general surgeons. Conclusion A consensus-based list of trauma care skills required by general surgeons was developed. This list can facilitate the development of a new trauma training course which has been optimized for general surgeons

Robotic Distal Gastrectomy With a Novel "Preemptive Retropancreatic Approach" During Dissection of Suprapancreatic Lymph Nodes for Gastric Cancer

Introduction: Abrogating contact with the pancreas in suprapancreatic lymph nodes dissection for gastric cancer can prevent pancreatic fistula because of postoperative pancreatic damage. Our novel "Preemptive retropancreatic approach" is a useful technique that minimizes pancreatic compression during robotic distal gastrectomy (RDG) with multijointed forceps. Here, we report the usefulness of RDG for gastric cancer surgery using our novel "Preemptive retropancreatic approach". Materials: "Preemptive retropancreatic approach": initial dissection of the bilateral retropancreatic space, the adherence between the retroperitoneum surface and the pancreas (fusion fascia) is released, providing a good operative field and hindering contact with the pancreas in suprapancreatic lymph nodes dissection during RDG. We herein reported consecutive 30 patients with gastric cancer who underwent RDG at Hokkaido University from September 2014 to March 2020. Results: All operations were performed by a single surgeon (Y.E.). The median operating time was 281 minutes (132 to 415). The median intraoperative bleeding was 0 ml of blood (0 to 255). There were 2 incidences of postoperative complications (>= Clavien-Dindo classification II), and there were no cases of postoperative pancreas-related complications. The median length of hospital stay after the surgery was 10 days (6 to 33). Conclusion: As RDG for gastric cancer is still in its early introductory phase, its superiority has yet to be definitively established. However, we believe that "Preemptive retropancreatic approach" may reduce postoperative pancreatic-related complications in suprapancreatic lymph nodes dissection

Short-term outcomes of robotic distal gastrectomy with the "preemptive retropancreatic approach" : a propensity score matching analysis

We report the usefulness of the preemptive retropancreatic approach (PRA) in robotic distal gastrectomy (RDG) using multi-jointed forceps. Therefore, this study aimed to compare the short-term outcomes of RDG with PRA and conventional laparoscopic distal gastrectomy using the propensity score matching method. A total of 126 patients [RDG = 55; laparoscopic distal gastrectomy (LDG) = 71] were retrospectively enrolled. Patients were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, the extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Surgical results and postoperative outcomes were compared. We identified 28 propensity score-matched pairs. The median operative time and blood loss were comparable (P = 0.272 and P = 0.933, respectively). Regarding postoperative outcomes, the incidence of postoperative complications [Clavien-Dindo classification II (CD >= II)] was lower in the RDG group than in the LDG group (P = 0.020). No significant differences in the peak C-reactive protein value and length of hospital stay were observed between the two groups (P = 0.391 and P = 0.057, respectively). In addition, no patients had postoperative pancreas-related complications (>= CD II) in the RDG group. RDG using PRA seems to be a safe and feasible procedure for gastric cancer because of short-term outcomes and reduction of postoperative complications (especially postoperative pancreas-related complications) as compared to conventional LDG

Effects of preoperative psoas muscle index and body mass index on postoperative outcomes after video-assisted esophagectomy for esophageal cancer

Introduction: Preoperative psoas muscle index (PMI) and body mass index (BMI) are relevant to postoperative outcomes. We investigated the associations of PMI, BMI, and preoperative nutritional and muscular score with postoperative outcomes in patients with esophageal cancer who underwent video-assisted surgery. Methods: We examined 150 patients (124 men, 26 women) who underwent video-assisted esophagectomy from February 2002 to March 2016. We used the Clavien-Dindo (CD) classification to analyze postoperative complications. Because skeletal muscle volume differs significantly between male and female patients, all analyses were performed separately. In male patients, we used the following cut-off values to categorize patients into three groups: PMI = 600 mm(2)/m(2), BMI = 18.5 kg/m(2), and preoperative nutritional and muscular (PNM) scores 0 to 2. Results: Two patients were converted to open thoracotomy. Among male patients, PMI and PNM scores were significant risk factors for complications. Among male patients, in the high PMI group, the number of CD >= IIIa complications was significantly lower. In the PNM score 0 group (both PMI and BMI values exceeded the cut-off values), the number of complications was significantly lower. In both genders, PMI and BMI were not significantly associated with survival. Conclusions: PMI and PNM scores can be useful for predicting postoperative outcomes in male patients with esophageal cancer having undergone video-assisted surgery

Where do we start? The first survey of surgical residency education in Japan

BACKGROUND: Currently, Japan does not have a national standardized program for surgical residency. Therefore, surgical education information and strategies are not shared among teaching hospitals. This was the first study aiming to clarify the current situation of surgical residency in Japan. METHODS: A questionnaire survey investigating the present situation of surgical residency was sent to the 76 teaching hospitals in Hokkaido Prefecture, Japan. RESULTS: The response rate was 64.5%. Data from the 36 hospitals with active residency programs were analyzed. Most of the program directors (79.4%) were in charge of educational work for less than 5 hours per week. Although half of the hospitals had skills laboratories or simulation centers, only 2 used them routinely for their residency program. Half of the hospitals evaluated the residents' competency and the quality of their educational programs. CONCLUSIONS: Structured programs and evaluation systems have not been integrated well into surgical residency in Japan

Robotic Distal Gastrectomy With a Novel “Preemptive Retropancreatic Approach” During Dissection of Suprapancreatic Lymph Nodes for Gastric Cancer

Introduction: Abrogating contact with the pancreas in suprapancreatic lymph nodes dissection for gastric cancer can prevent pancreatic fistula because of postoperative pancreatic damage. Our novel "Preemptive retropancreatic approach" is a useful technique that minimizes pancreatic compression during robotic distal gastrectomy (RDG) with multijointed forceps. Here, we report the usefulness of RDG for gastric cancer surgery using our novel "Preemptive retropancreatic approach". Materials: "Preemptive retropancreatic approach": initial dissection of the bilateral retropancreatic space, the adherence between the retroperitoneum surface and the pancreas (fusion fascia) is released, providing a good operative field and hindering contact with the pancreas in suprapancreatic lymph nodes dissection during RDG. We herein reported consecutive 30 patients with gastric cancer who underwent RDG at Hokkaido University from September 2014 to March 2020. Results: All operations were performed by a single surgeon (Y.E.). The median operating time was 281 minutes (132 to 415). The median intraoperative bleeding was 0 ml of blood (0 to 255). There were 2 incidences of postoperative complications (>= Clavien-Dindo classification II), and there were no cases of postoperative pancreas-related complications. The median length of hospital stay after the surgery was 10 days (6 to 33). Conclusion: As RDG for gastric cancer is still in its early introductory phase, its superiority has yet to be definitively established. However, we believe that "Preemptive retropancreatic approach" may reduce postoperative pancreatic-related complications in suprapancreatic lymph nodes dissection